Report details response to strep outbreak in Anchorage homeless population

An infectious outbreak of a new, virulent strain of strep bacteria led to three deaths in Anchorage's homeless population among five deaths statewide but appears to be declining now that health officials took the unprecedented step of distributing antibiotics and antiseptic body wash at shelters over the winter.

In a new report released Tuesday, officials describe in detail the unusual concentration in Anchorage of infections tied to the strep bacteria, which disproportionately affected people who were homeless and addicted to alcohol.

The outbreak grew severe enough to prompt a visit from an Atlanta-based intervention team from the federal Centers for Disease Control and Prevention.

Between February 2016 and April 2017, health officials diagnosed 54 cases of the strep strain. Since July, 41 of those cases have been diagnosed in Anchorage.

It was Alaska's first-ever outbreak of this type of strep bacteria, officials said.

For this new strain, the complications could be severe, ranging from septic shock to a fast-spreading bacterial skin infection called necrotizing fasciitis. Statewide, five people died — three in Anchorage and two in Fairbanks. Three people lost limbs. Everyone who developed the infection was hospitalized, some for more than three months.

The infection largely spread through shared blankets and drink containers, the state report concluded. Most of the people infected were homeless or had contact with a homeless shelter or a person who was homeless.

A common thread was alcohol abuse, in contrast with outbreaks of the strain elsewhere in the world, where drug injections linked the cases. Alcoholism is known to weaken the immune system, said Joe McLaughlin, chief of epidemiology for the state health department.

McLaughlin said health officials still consider it a mystery why the outbreak particularly took hold in Anchorage's homeless population.

"But we do know that people affected with homelessness are more likely than the general population to have underlying medical conditions that are not well cared for, to congregate in homeless shelters, group kitchens and homeless camps, and to have less access to showers and other means to ensure personal hygiene," McLaughlin said.

In a proposal to the Anchorage Assembly, the administration of Mayor Ethan Berkowitz pointed to the strep outbreak as one reason to keep the city's winter emergency shelters open year-round for the next two years. City homeless coordinator Nancy Burke said the dispersal of homeless individuals in outdoor camps would make it more difficult to coordinate medical aid.

It's unusual for cases of this type of strep bacteria to cluster at a certain place and time, said Emily Mosites, an epidemic intelligence service officer on a fellowship with the Centers for Disease Control and Prevention's Arctic Investigations Program, and the lead author on the new report.

"The response required some innovative thinking," Mosites said.

At least 10 strains of what's called "Group A streptococcus" have been identified in Alaska, McLaughlin said. Doctors diagnose up to a few dozen cases every quarter.

In early 2016, a new strain emerged in Fairbanks, catching the attention of health officials.

There weren't obvious connections between the patients in Fairbanks. But by the end of the summer, three cases had popped up in Anchorage, all in people who were homeless.

In the face of a possible outbreak, the state launched an investigation in Anchorage with federal and local government health agencies. A questionnaire asked patients when and where they were getting sick.

The medical clinic at the Brother Francis Shelter in downtown Anchorage — identified as "Shelter A" in the report — expanded its hours to diagnose cases more quickly. Between December and January, the Alaska Native Medical Center and Alaska Regional Hospital donated lab services to grow swab cultures taken by the clinic. Health workers offered antibiotics to anyone who tested positive.

In November, with two people dead and case counts mounting, the state released a public health alert. Officials had identified 26 cases of the strep strain. Of 16 patients who agreed to be interviewed, nearly all were homeless shelter clients — no shelter staff were infected.

Even while targeting people who were most at risk of contracting the infection, the number of cases in January exceeded those diagnosed in December.

That forced a shift in strategy, according to the report. An Atlanta-based team from the federal Center for Disease Control and Prevention flew to Anchorage to help with an intervention. Officials settled on a much broader approach — to offer antibiotics and antiseptic body wash to as many homeless shelter clients as possible.

At that point, the strep response guidelines issued by the federal government had no specific information on an outbreak in a homeless population, McLaughlin said.

In February, between 10 and 12 doctors, pharmacists, nurses and public health staff visited six homeless services sites. Homeless clients were evaluated before receiving antibiotics. The team also interviewed clients and took saliva and skin swabs to test whether the person was carrying the strep bacteria but not showing symptoms.

Nearly 400 people received antibiotics that month, McLaughlin said. The team also distributed 300 bottles of antibiotic soap to the showers in the homeless shelters, though few people actually used it, according to the report.

Health officials have since recorded a "precipitous" drop in case counts, McLaughlin said. He said the apparent direction of the trend is encouraging. Shelter clients should report any early signs of skin infection to a health care provider as soon as possible, McLaughlin said.

Mosites said the bacteria hasn't been entirely eradicated from Anchorage's homeless population, however.

"We'll certainly be continuing to keep track of it and make sure it doesn't do anything unusual again," Mosites said.